床旁B型利钠肽检测与全球急性冠状动脉事件注册评分对急性冠状动脉综合征患者的预后价值

目的 评价急性冠状动脉综合征(ACS)患者人院时B型利钠肽(BNP)水平对于患者30 d预后终点的意义,并与全球急性冠状动脉事件注册(GRACE)评分进行比较,以探讨ACS患者危险分层的理想方法.方法发病24 h内的ACS患者,床旁检测入院时BNP水平,同时计算患者的GRACE评分.随访30 d的终点事件,包括死亡、再发缺血或心肌梗死及新发生的心力衰竭.通过受试者工作曲线(ROC)分析BNP和GRACE评分预测30 d终点事件的预测价值和界值,并通过logistic回归比较二者的独立预测价值.结果入选ACS患者246例,ST段抬高心肌梗死135例(54.9%),非ST段抬高心肌梗死患者111例(45.1%).年龄为31～91(67.6 4-12.0)岁,男性152例(占61.8%).随访30 d共发生终点事件34例(13.8%),其中死亡9例(3.7%).终点事件组(n=34)患者入院时收缩压低于对照组(n=212,P=0.034),而心率和血肌酐水平均明显高于对照组,但是两组间C反应蛋白和肌钙蛋白Ⅰ差异无统计学意义.终点事件组GRACE评分(中位数164.5比142.0,P=0.002)和BNP水平(中位数883.5ng/L比216.5 ng/L,P=0.002)均明显高于对照组.通过ROC分析,预测30 d终点事件的BNP界值为194.5 ng/L(曲线下面积0.704,P=0.043),GRACE评分的界值为158(曲线下面积0.742,P=0.003),GRACE评分的敏感性和特异性(分别为72.8%和81.4%)较BNP水平稍高(敏感性67.6%,特异性64.6%),但曲线下面积比较差异无统计学意义(Z=1.223,P＞0.05).logistic回归模型中二者均为独立危险凶素,BNP＞194.5 ng/L的OR值为3.174,GRACE评分＞158的OR值为4.031,预测的符合度较好.结论入院时的BNP水平和GRACE评分均是ACS患者30 d预后的独立预测指标,床旁BNP具有快速、方便的特点,但其对ACS患者预后的界值还需要更多的研究验证.

Prognostic value of point of care B-type natriuretic peptide testing and GRACE score in patients with acute coronary syndrome

Objective To compare the prognostic value of B-type natriuretic peptide (BNP) and GRACE score in patients with acute coronary syndrome. Methods A total of 246 patients with chest pain to hospital time < 24 hours were followed up to 30 days. Admission plasma B-type natriuretic peptide was measured by point-of-care. Endpoints included death, reinfarction, recurrent ischemia and new onset of congestive heart failure. The receiver operating characteristic (ROC) curve was used to evaluate prognostic value of BNP and GRACE score. The logistic regression models were used to assess the prognostic contribution of BNP level and GRACE score. Results The mean age was (67. 6 ± 12. 0) years (61. 8% males) and ST elevation myocardial infarction (STEMI) was diagnosed in 135 patients (54.9% ). During the follow up, 34 endpoints ( 13. 8% ) were recorded including 9 deaths (3.7%). The systolic blood pressure [(121 ±29)mm Hg vs. (130±23)mm Hg, P=0.034; 1 mm Hg=0. 133 kPa] was significantly lower while the heart rate and plasma creatinin were significantly higher in the endpoints group than in non-endpoints group. TNI and CRP levels were similar between the two groups. The BNP level at admission (median 883.5 ng/L vs. 216.5 ng/L) and GRACE score (median 164.5 vs. 142.0) were significantly higher in the endpoints group than in non-endpoints group (all P <0. 05). The prognostic criteria for BNP level (area under cure, 0.704) was 194.5 ng/L determined by ROC(P=0. 043). For GRACE score, the predictive value for endpoints was 0. 742 ( P = 0. 003 ) and the cut-off point was 158. In the logistic regression model, BNP concentration ( > 194.5 ng/L, OR =3. 174) and GRACE score ( > 158, OR = 4. 031) were independent predictors of endpoints in patients with ACS. Conclusion Both BNP level at admission and GRACE score were independent predictors for endpoints at 30 days in patients with ACS.